Interesting article. I thought our members would be interested. An element of caution, it is slightly long.
        Amit Ghosh


> This article from NYTimes.com
>
>
>
> What Doctors Don't Know (Almost Everything)
>
> May 5, 2002
>
> By KEVIN PATTERSON
>
>
>
>
> I work as an internist in the Canadian Arctic, in a region
> called Kivalliq, on the west coast of Hudson Bay. There are
> no highways there, and the more recent social changes of
> the south have not penetrated the tundra any more deeply
> than the road system has. The eyewear is distinctly out of
> fashion, and the church remains influential.
>
> In Kivalliq, interaction between patients and physicians is
> not characterized by lengthy debate. People expect to
> receive prescriptions and proscriptions; these are
> provided, and patients generally keep their opinions to
> themselves. It is the postcolonial era, but not by much.
>
> I also work on Vancouver Island, and there, the eyewear is
> outlandish and churches are being sued everywhere. The
> interaction between patients and physicians, however, is
> the least different thing about the two places. There is
> somewhat more dialogue in the south, to be sure, but the
> tone of the interaction is for the most part lodged in the
> Edwardian era. You must stop smoking. If you don't lose
> weight, you're destined for diabetes. You have congestive
> heart failure. Here is a prescription for the drugs you
> need to take; please don't forget. The finger wagging is
> unceasing.
>
> Medicine has clung to a sense of hierarchy that is being
> abandoned elsewhere. Teachers answer to parents and bankers
> solicit borrowers, but in medicine, a chain of command has
> existed since the profession found its modern face --
> doctor's orders -- with the most senior and academic
> physician experts directing the decisions of specialists,
> family physicians and ultimately the patients.
>
> This order is now in the throes of a revolution known as
> evidence-based medicine, which asserts the supremacy of
> data over authority and tradition. For doctors these days,
> the revolution is everywhere; you can't kick over a bedpan
> without hearing the phrase ''evidence-based medicine''
> rattle out. Outside the hospital walls, though, word has
> been slower to travel.
>
> E.B.M. is, as revolutions go, a little unlikely. Its
> motives are not primarily political, although its effects
> ultimately are. And those effects -- the various ways in
> which information subverts hierarchy -- are beginning to
> change medicine fundamentally. What began as a pragmatic
> undertaking has become a philosophical and political
> transformation, and it is creating a dramatic shift in the
> relationship between doctors and patients.
>
> Until recently, the guiding principle in medicine has been
> Aristotelian: an understanding of the disease comes first,
> before experimentation. On the face of it, the approach
> isn't outrageous; doctors try to understand the nature of
> the ailment they are addressing, and then they try to think
> of an intervention -- an operation or a pill or a type of
> psychotherapy -- that goes to the essence of the problem.
> And this method often works. For instance, when Frederick
> G. Banting and Charles H. Best identified the role a
> deficiency of insulin played in the development of juvenile
> diabetes, the treatment that suggested itself -- replacing
> the insulin -- turned out to be a huge success. Banting and
> Best's discovery was a model of how medicine advanced
> through most of the 20th century. Research was based on
> this simple, rational premise: understand the problem, and
> its solution will become self-evident.
>
> But people, doctors included, have a tendency to see what
> they expect to see. It's the premise of every
> sleight-of-hand game. If it makes sense that a treatment
> will work -- or if one stands to make money if a treatment>
> works -- then a doctor will, with alarming and
> disheartening reliability, perceive that it does in fact
> work. What is surprising is that a profession that dresses
> itself up in the garb of science has taken so long to
> acknowledge a principle that every small-town carny
> understands.
>
>
> When I started practicing medicine in the early 90's, one
> of my enthusiasms was hormone-replacement therapy. At that
> time, the observation had been made, repeatedly, that
> postmenopausal women who happened to take estrogen -- for
> osteoporosis or hot flashes, for instance -- were less
> likely to have heart attacks and strokes than women who
> didn't. I remember telling women in their 50's how
> premenopausal women were relatively immune to
> cardiovascular disease, at least compared with men, but
> that once they had been through menopause, this relative
> protection disappeared quickly. ''Take the estrogen,'' I
> suggested over and over. ''Preserve your youthful
> coronaries.''
>
> This was in Manitoba, and these were pragmatic, sensible
> prairie women. I insisted to them that the recommendations
> and the evidence seemed clear. I remember my patients'
> brows knitting at the thought of menstrual cycles extending
> into their dotage, but ultimately the argument felt
> compelling. Certainly it did for me. I remembered being
> told in medical school that the underuse of estrogen was
> one of the great crimes of the medical patriarchy, itself
> an expression of latent misogyny. No misogynist I, off I
> went to work, my prescription pad leaping to hand at the
> sight of bifocals or pastel cardigans.
>
> Then in 1998, the results of a formal, placebo-controlled
> clinical trial called the Heart and Estrogen/Progestin
> Replacement Study (HERS) were published. It showed that
> estrogen did not prevent heart attacks or strokes and, in
> fact, it made women more susceptible to blood clots. The
> net cardiovascular effect therefore was negative. This
> study astonished most doctors -- for me, it certainly felt
> like a betrayal. Betrayed by the recommendations, we had in
> turn betrayed many of the cardigan-clad women of our
> acquaintance.
>
> A few months ago, in the emergency room of one of the
> hospitals I work in on Vancouver Island, I saw a woman in
> her mid-70's who was still taking Premarin, a common
> estrogen preparation. She had been having chest pain, and I
> was admitting her for observation, to make sure she wasn't
> having a heart attack.
>
> ''So, you take the Premarin because . . . ?'' I asked.
>
>
> ''My sisters all had heart attacks in their 50's,''she
> said. ''My doctor said the estrogen lowered my risk.''
>
> ''We now think it probably doesn't.''
>
> ''Really.''
>
>
> ''Yes.'' Me, nodding, smiling weakly.
>
> ''What changed?''
>
> ''Well, there were these studies that
> seemed to show that women who took estrogen had a
> relatively low incidence of heart attacks, but it turns out
> that really, it was the sort of woman who took estrogen who
> was less likely to have a heart attack. She was probably
> also less likely to smoke, more likely to seek regular
> medical attention -- she did something important different,
> anyway. When, just recently, they took a large group of
> women and randomly gave each woman either a placebo or
> estrogen, the ones taking estrogen didn't do at all
> better.''
>
> ''Well,'' she said. ''Isn't that something?''
>
> My patient was not alone. The data from HERS were so
> surprising that many health-care providers seem not to
> believe them, even today. In 2001, Premarin was the third
> most-prescribed drug in the United States.
>
>
> Until only a few generations ago, the prevailing conception
> of illness was that the sick were contaminated by some
> toxin or contagion or an excess of one humor or another.
> That understanding of illness contained within it the idea
> that these conditions could be improved by opening a vein>
> and letting the sickness run out: bloodletting, the
> practice was called.
>
> Once the toxins were gone, the patient immediately felt
> different, and often better. As anyone who has given blood
> can tell you, losing a pint or two can make you feel
> transported, transformed. Intuitively, it was satisfying to
> doctors that the procedure left the patient feeling drained
> -physically, emotionally and into the sink.
>
> It is understood now that bloodletting only hastened the
> death of the ill. (George Washington had almost five pints
> of blood drained from him in the two days prior to his
> death; he had been suffering from a sore throat.) We know
> that bloodletting is unhelpful because a Parisian doctor
> named Pierre Louis did an experiment in 1836 that is now
> recognized as one of the first clinical trials. He treated
> people with pneumonia either with early, aggressive
> bloodletting or less aggressive measures; at the end of the
> experiment, Dr. Louis counted the bodies. They were stacked
> higher over by the bloodletting sink.
>
> No sooner had the message about the dangers of draining
> blood out of patients been conveyed across the medical
> community -- and that took the rest of the 19th century --
> than doctors developed a new passion for pouring it back
> into them. After crosstyping was invented and blood could
> be transfused safely, doctors quickly decided that very ill
> patients do better with as normal a level of hemoglobin as
> could be maintained. It made sense, and blood transfusions
> became a routine part of critical-care medicine.
>
> Then just three years ago the results of a large study
> called Transfusion Requirements in Critical Care were
> published in The New England Journal of Medicine. Those
> results shook the community of intensive-care physicians
> worldwide. Except in the case of people with unstable
> angina and acute myocardial infarction, routine transfusion
> of critically ill people with moderate or mildly low
> hemoglobin levels does not decrease their mortality rate --
> and in some subgroups, it actually increases the mortality
> rate. Nobody has a convincing explanation for why this is,
> but it is the case.
>
> The essential tenet of evidence-based medicine is that
> patients, working with their physicians and armed with
> medical data, are better equipped to make decisions that
> work for them than doctors of the Marcus Welby model are,
> because they understand their own expectations better than
> their physicians can. Authority is devolved from expertise
> to the data and thus, ultimately, to the patient. In an
> E.B.M. world, the physician makes diagnoses, serves as a
> conduit of the medical data and is responsible for framing
> those data and putting them into context, but the
> responsibility for the decision becomes the patient's.
> Patients have always had the final say about whether to
> accept the recommendations of their physicians, but without
> the actual data in front of them, the decision has simply
> been whether or not to trust the wisdom of the physician.
> E.B.M. tries to move that judgment to the steadier ground
> of data.
>
> The point isn't that some medical treatments don't work as
> well as it is thought, or even that in treating patients,
> doctors sometimes hurt them -- this has always been true.
> The point is that the conclusions doctors reach from
> clinical experience and day-to-day observation of patients
> are often not reliable. The vast majority of medical
> therapies, it is now clear, have never been evaluated by
> systematic study and are used simply because doctors have
> always believed that they work.
>
> The manifesto of the evidence-based-medicine movement
> appeared in The Journal of the American Medical Association
> in 1992, written by a group of doctors led by an
> internal-medicine specialist in Hamilton, Ontario, named>
> Gordon H. Guyatt. The publication ignited a debate about
> power, ethics > and responsibility in medicine that is now
> threatening to radically change the experience of health
> care.
>
> ''If you said to most members of the general public,
> 'Physicians have been trained in such a manner that they
> have no idea how to read a paper from the original medical
> literature or how to interpret it,' that would surprise the
> public,'' Guyatt says. ''The public's image of physicians
> has been such that it would be shocking to them that there
> hasn't always been evidence-based practice.''
>
> From the first day in the cadaver room and on, every
> medical student is drilled with this truism: ''Medicine is
> both an art and a science.'' The ''art'' is represented to
> be the physician's intuitive sense of a patient and her
> underlying diagnoses and how she might respond to certain
> treatments.
>
> And intuition is certainly an indispensable part of
> medicine. The body is so complex, and the ways it might go
> wrong so varied, that in the middle of the night, standing
> next to some fresh catastrophe, a doctor sometimes needs to
> generalize and to reduce very complicated problems to first
> principles. It is simply not possible to be rigorously
> intellectual and consult the available medical data about
> every single thing, all the time. It takes too long, and if
> all the intricacies of the medical data on every clinical
> problem were fully considered before acting, the operating
> rooms would grow dusty and people would die while the
> doctors' chins were rubbed into a bright shine. Sometimes
> it is necessary to act on a feeling.
>
> And so medicine has intellectual shortcuts: intuitions and
> axioms and rules of thumb: ''Never let the sun set on an
> abscess'' (operate early when you find one) or on a more
> particular note, ''Gerald hasn't looked right for months
> now; this isn't just a cold.''
>
> The feeling, the art, is precisely what is appealing about
> medicine for doctors. It is personal and warm, and
> dramatic, pithy platitudes about the indications for
> surgery are easier to remember and more satisfying to cite
> than the constantly changing and dry data on outcomes. But
> in the end, the art is simply what one wants it to be. And
> if a doctor simply feels that blood transfusions are good
> for people with pneumonia, should that be enough reason to
> transfuse them?
>
> The answer has always been, pretty much, yes. Clinical
> impressions do matter and ought to be taken seriously. When
> an experienced neonatology nurse doesn't like the look of
> an infant, for instance, a pediatrician takes that very
> seriously, or quickly learns to, even if there is no fever
> or abnormal lab results. It sounds a little like magic,
> this art. And once you believe a little in magic, it's hard
> to imagine there's anything it can't do.
>
> Nuala Kenny, a physician-ethicist at Dalhousie University
> in Halifax, Nova Scotia, and a critic of evidence-based
> medicine, defends intuitive reasoning: it isn't a lazy way
> of thinking, she argues, but rather a sophisticated type of
> thought that incorporates many variables and tremendous
> amounts of data from previous experience. It's the reason
> that Kasparov can still beat Deep Blue from time to time.
>
> ''Scientific data cannot be expected to guide most medical
> decisions directly,'' she wrote in one critique. ''There
> are not enough randomized trials or epidemiologic studies;
> there are virtually no studies on appropriate ordering of
> tests. The randomized clinical trial has become the gold
> standard but . . . it is a leap of faith to expand the
> results of a trial to a broad therapeutic principle.
> Clinicians recognize this instinctively. The best drug, the
> optimal dose and duration of therapy for a particular
> patient are not determined directly by a study involving a
> large population.''
>
> Kenny sees E.B.M. as a threat to the individual>
> practitioner, another step toward the mechanization of
> medicine. Guyatt emphasizes that> E.B.M. gives the
> individual practitioner the tools to defend iconoclastic
> practice with data. E.B.M. represents a more skeptical
> approach to practicing medicine, but at the same time a
> more open one, Guyatt argues. If the data support an
> intervention, even if it is herbal or crystal-based or
> otherwise magical-seeming, then the intervention should be
> put into practice. St. John's Wort, for instance, has been
> demonstrated to be an antidepressant of modest potency in
> randomized clinical trials and thus, in the E.B.M.
> worldview, there is nothing ''alternative'' about it.
>
> The disagreement is really over the value of intuition: the
> E.B.M. position is that there are reliable, validated data,
> and then there are data that aren't reliable and validated,
> and that's really what matters. This difference may never
> be resolved through debate; it might be the difference
> between having faith and not having it.
>
>
> The most radical change E.B.M. proposes will occur in
> everyday visits in doctor's offices -- those simple, scary
> moments when the most important medical decisions are made.
> The instant the practitioner stops saying, ''I think you
> should take this therapy,'' and starts saying, ''The
> evidence is that this therapy will work this percent of the
> time, with these complications, this frequently; what do
> you want to do?'' then the power hierarchy of doctor over
> patient is collapsed, and autonomy is assigned to the
> patient. This is how the relationship between doctor and
> patient could be changed by evidence-based medicine. Just
> as the idea of authority within medicine is rejected, so
> too, the idea of the profession of medicine itself having
> authority over the patient is rejected. Giving authority to
> the data, instead of other people, empowers everyone, the
> movement holds.
>
> It isn't clear that patients will embrace evidence-based
> medicine. Human beings are social creatures, and we don't
> necessarily want to have to make up our own minds about
> absolutely everything, especially if doing so requires
> trips to the library and afternoons on the Internet and
> hours of reflection.
>
> Practitioners are also resistant to E.B.M., simply because
> it marks a change in the idea of what doctors are. It is a
> signal that in medicine, ours is a less heroic age. The
> dramatic cures have stopped coming. Penicillin for
> meningitis, streptomycin for tuberculosis, Salk and polio:
> what those days of discovery must have been like, with
> self-evident cures trotting forth regularly for all the old
> killers. Everyone used to die of this, now almost everyone
> recovers -- the only trick is in making the diagnosis. How
> satisfying it must have been, how easy to feel potent.
>
> Now we die of things like congestive heart failure:
> diseases that haven't submitted to easy, magic-bullet cures
> and have the habit of announcing their presence quietly
> when they are already well advanced. These diseases are
> pared away incrementally, the mortality rate decreased by a
> few percentage points with this maneuver, a few more with
> that one. A number of things help a bit; nothing helps a
> lot.
>
> So the warriors are being replaced by the accountants. The
> 28 percent response rate is traded for the 31 percent
> response rate; differences in effectiveness that are too
> subtle to be noticed by an individual practitioner justify
> ongoing refinements in therapy. The numbers dictate the
> changes, and each year the outlook is slightly better.
>
> Accountants know the whole world thinks their lives are
> gray -- demeaned by all that addition. Doctors aren't used
> to thinking of themselves that way. But in the real world,
> where numbers matter, accountants know how powerful they
> are. Doctors now have to learn the same lesson.
>
> No one knows where the ongoing renegotiation of the
> complicated relationship between the individual and>
> society, which lies at the heart of E.B.M., is going> to
> end. At the same time that the individual increasingly
> demands control of his life, money and expression, he also
> clearly still wants to be protected by society from
> corporate interests and economic vagaries, and to be taken
> care of when he is sick. This ambivalence about
> independence is an essentially human trait, as is a certain
> ambivalence about empiricism itself. The story is as old,
> and Greek, as the Hippocratic tradition itself: what
> empowers us sometimes demeans us.
>
>
>
>
> Kevin Patterson is an internist and the author of ''The
> Water in Between: A Journey at Sea.''
>
> http://www.nytimes.com/2002/05/05/magazine/05EVIDENCE.html?ex=1033288424&ei=1&en=774dec27e3afcc10
>
>
>
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